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Chapter 4: Mental Health Policy and Service Provision :
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Promoting research
Although knowledge of mental and behavioural disorders has increased over the years, there still remain many unknown variables which contribute to the development of mental disorders, their course and their effective treatment. Alliances between public health agencies and research institutions in different countries will facilitate the generation of knowledge to help in understanding better the epidemiology of mental disorders, and the efficacy, effectiveness and cost-effectiveness of treatments, services and policies.
Epidemiological research
Epidemiological data are essential for setting priorities within health and within mental health, and for designing and evaluating public health interventions. Yet there is a paucity of information on prevalence and the burden of major mental and behavioural disorders in all countries, particularly in developing countries. Similarly, longitudinal studies examining the course of major mental and behavioural disorders and their relationship with psychosocial, genetic, economic and other environmental determinants are lacking. Epidemiology, amongst other things, is also an important tool for advocacy, but the fact remains that many countries lack data to support advocacy for mental health.
Treatment, prevention and promotion outcome research
The burden of mental and behavioural disorders will only be reduced if effective interventions are developed and disseminated. Research is needed to develop more effective drugs which are specific in their action and which have fewer adverse side-effects, more effective psychological and behavioural treatments, and more effective prevention and promotion programmes. Research is also needed on their cost-effectiveness. More knowledge is required to understand what treatment, either singly or in combination, works best and for whom. Adherence to a treatment, prevention or promotion programme can directly affect outcomes, and research is also needed to help understand those factors affecting adherence. This would include examination of factors related to: the beliefs, attitudes and behaviours of patients and providers; the mental and behavioural disorder itself; the complexity of the treatment regime; the service delivery system, including access and treatment affordability; and some of the broad determinants of mental health and ill-health, for example, poverty.
There remains a knowledge gap concerning the efficacy and effectiveness of a range of pharmacological, psychological and psychosocial interventions. While efficacy research refers to the examination of an intervention's effect under highly controlled experimental conditions, effectiveness research examines the effects of interventions in those settings or conditions in which the intervention will ultimately be delivered. Where there is an established knowledge base concerning the efficacy of treatments, as is the case for a number of psychotropic drugs, there needs to be a shift in research emphasis towards the conduct of effectiveness research. In addition, there is an urgent need to carry out implementation or dissemination research into those factors likely to enhance the uptake and utilization of effective interventions in the community.
Policy and service research
Mental health systems are undergoing major reforms in many countries, includingde-institutionalization, the development of community-based services, and integration into the overall health system. Interestingly, these reforms were initially stimulated by ideology, the development of new pharmacological and psychotherapeutic treatment models, and the belief that alternative forms of community treatment would be more cost-effective. Fortunately there is now an evidence base, derived from a number of controlled studies, demonstrating the effectiveness of these policy objectives. Most of the research to date has, however, been generated in industrialized countries and it is questionable whether results can be generalized to developing countries. Research is therefore needed to guide reform activities in developing countries.
Given the critical importance of human resources for administering treatments and delivering services, research needs to examine the training requirements for mental health providers. In particular, there is a need for controlled research on the longer term impact of training strategies, and the differential effectiveness of training strategies for different health providers working at different levels of the health system.
Research is also needed to understand better the important role played by the informal sector and if, how and in what ways the involvement of the traditional healers can either enhance or adversely affect treatment outcomes. For example, how can primary health care staff better collaborate with traditional healers in order to improve access, identification and successful treatment of persons suffering from mental and behavioural disorders? More research is required to understand better the effects of different types of policy decisions on access, equity and treatment outcomes, both overall and for the most disadvantaged groups. Examples of research areas include the type of contracting arrangement between purchasers and providers that would lead to better mental health service delivery and patient outcomes, the impact of different methods of provider reimbursement schemes on access and use of mental health services, and the impact of integrating budgets for mental health into general health financing systems.
Economic research
Economic evaluations of treatment, prevention and promotion strategies will provide useful information to support rational planning and choice of interventions. Although there have been some economic evaluations of interventions for mental and behavioural disorders (for example, schizophrenia, depressive disorders and dementia), economic evaluations of interventions in general tend to be scarce. Again the overwhelming majority come from industrialized countries.
In all countries, there is a need for more research on the costs of mental illness and for economic evaluations of treatment, prevention and promotion programmes.
Research in developing countries and cross-cultural comparisons
In many developing countries there is a notable lack of scientific research on mental health epidemiology, services, treatment, prevention and promotion, and policy. Without such research, there is no rational basis to guide advocacy, planning and intervention (Sartorius 1998b, Okasha & Karam 1998).
Despite many similarities of mental problems and services across countries, the cultural context in which they occur can differ substantially. Just as programmes need to be culturally informed, so does research. Research tools and methods should not be imported from one country to another without careful analysis of the influence and effect of cultural factors on their reliability and validity.
WHO has developed a number of transcultural research tools and methods including the Present State Examination (PSE), Schedule for Comprehensive Assessment in Neuropsychiatry (SCAN), Composite International Diagnostic Interview (CIDI), Self Reporting Questionnaire (SRQ), International Personality Disorder Examination (IPDE), Diagnostic Criteria for Research (ICD-10DCR), World Health Organization Quality of Life Instrument (WHOQOL), and World Health Organization Disability Assessment Schedule (WHODAS) (Sartorius & Janca 1996). These and other scientific tools need to be further developed to allow valid international comparisons that will help in understanding the commonalities and differences in the nature of mental disorders and their management across different cultures.
One lesson of the past 50 years is that tackling mental disorders involves not only public health but also science and politics. What can be achieved by good public health policy and science can be destroyed by politics. If the political environment is supportive of mental health, science is still needed to advance understanding of the complex causes of mental disorders, and to improve their treatment.
Chapter 4: Mental Health Policy and Service Provision :
1,2,3,4,5
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